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June 5, 2017

Depression, Part 2: Management

Happy Monday! Hope you had a nice weekend! I’m back today with the second post in a 3-part series on depression. (Here’s a link to the first post, in case you missed it!). Last time, we talked about routine screening for depression and its diagnosis, and today we’ll discuss how to manage depression in the primary care setting. As always, it’s important to know the limits of your training, scope of practice, and clinical setting; I am a family nurse practitioner, not a psychiatric-mental health nurse practitioner, which means that I don’t have as much training (obviously) in mental health management as a PMHNP. However, in the vast majority of cases, I can manage patients who have major depressive disorder in primary care; patients who have bipolar disorder, schizophrenia, or other mental health conditions, though, are best served by a psychiatric provider, so I refer those patients on. And, hopefully it goes without saying but in case it doesn’t, an actively suicidal or homicidal patient needs immediate intervention and should be transferred to the ED right away. OK. Now that all that’s out of the way, let’s get to management of depression!

Once the diagnosis of depression is established, I typically talk to patients about what our management options are. I typically say, “There are 5 things that have been shown to be helpful for patients with depression. Let me go through them with you, and then we’ll see what you think.” Here are the 5 things I discuss with my patients, and the way I typically present them (also, I always go in the same order so I don’t forget any!):

Medication – Just like hypertension or diabetes or most any other chronic disease, we know that depression is caused by an imbalance of substances in the body. In the case of depression, it’s dopamine, serotonin, and norepinephrine that are recycled too quickly; medications can help to rebalance the amount of these neurotransmitters in the brain which affect mood and make a big difference for a lot of people.

Counseling/Therapy – A lot of people find it extremely helpful to sit down with a trained professional on a regular basis (once a week, once every two weeks, once a month, whatever works for you…) and have the opportunity to talk with someone who is trained to help a person think through and process what’s going on in their life, and help make a plan for coping. For some people, this sounds like the most terrifying thing in the world, but for a lot of people it’s very helpful.

Exercise – Studies have shown us that getting regular aerobic exercise (about 30 minutes most days of the week) helps to boost mood. It doesn’t matter what that exercise is or whether weight changes at all; it simply helps to get the body moving doing something you enjoy, whether it be walking, yoga, swimming, hiking, or whatever.

Social support – This does not mean having 47 friends. It is important to have at least one or two solid people in your life that you can count on, the people who know what’s going on with you and stand with you, the people you can call at 3am if needed.

A sense of purpose/meaning for your life – I see a lot of patients with depression shortly after they get laid off from a job, or after they retire, or after someone they’ve cared for (ie. their children) no longer needs their care. For a lot of people, their job is their sense of purpose; they feel like they contribute to the world around them through what they do Monday to Friday from 9-to-5. But it doesn’t have to be a job; what’s important is that you find something that you can do within the limits of your own skill-set and availability to contribute to the community around you. For example, if you really care about animals, volunteer at the SPCA a couple of times a week to walk the dogs that would otherwise be stuck in cages all day, every day; if you do that, you are changing the world for those dogs, and their lives are different for you being in it. I don’t care what the cause is, but find something that you care about – helping an elderly neighbor, volunteering at a soup kitchen, whatever – and commit to doing it. You have something to contribute to the world, and it’s important that you have a reason to get out of bed every morning.

After I got through all of these, I typically recap them – medication, counseling, exercise, social support, and a sense of purpose – and say, “So what do you think? Where do you want to start?” Typically, patients will have been listening intently and identify 1 – 3 places to start, and I always follow their lead on this. If they want to start with medication, I typically start with Effexor (venlafaxine XR) 37.5 mg once daily. If they would like to proceed with counseling, I give them a typed list of local contacts I’ve developed (I highly recommend making a similar one for your local area!). If they’d like to try exercise, I try to get them to nail down what they’ll try and how often. If they lack social support but think that’s important, I encourage them to start attending a church or community organization they might be interested in to find like-minded individuals. And if it’s finding a sense of purpose, I ask them to identify one or two areas that they might find meaningful.

Regardless of where we start, I typically see them back in 4 – 6 weeks to re-evaluate how they’re doing. The antidepressants typically take about 4 weeks to start making meaningful changes in a patient’s symptoms, so by seeing them at 4 – 6 weeks we can assess if we need to make dose or medication adjustments. If the patient has elected not to start medication but is instead pursuing another treatment modality, that gives them some time (but not too much to procrastinate too much) to start making progress towards those plans. At the follow-up visit, I’ll have the LPN re-administer the PHQ-2 (and if needed, the PHQ-9) to see if we’ve made any progress and to determine how to move forward together.

I’ll be back soon with a post specifically outlining medication management for depression.

Is there anything other than the 5 components I listed above that you find helpful in discussing depression treatment with your patients? I’d love to hear!

Note: This is the 2nd post in a 3-part series on depression management. Click here to read the 1st post about screening and diagnosis!

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Welcome!

Hi There! I'm so glad you're here! I'm Cheryl, and I'm the novice NP. I'm a nurse practitioner in Virginia and I've been in practice for a little over a year, but am still new(ish) to the world of health care and hope to share what I'm learning here. xo Cheryl